Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.

BACKGROUND: Inadequate health literacy is prevalent among seniors and is associated with poor health outcomes. At hospital discharge, medications are frequently changed and patients are informed of these changes via their discharge instructions. OBJECTIVES: Explore the association between health literacy and medication discrepancies 48 hours after hospital discharge and determine the causes of discharge medication discrepancies. DESIGN: Face-to-face surveys assessing health literacy at hospital discharge using the short form of the Test of Functional Health Literacy in Adults (sTOFHLA). We obtained the medication lists from the written discharge instructions. At 48 hrs post-discharge, we phoned subjects to assess their current medication regimen, any medication discrepancies, and the causes of the discrepancies. PARTICIPANTS: Two hundred and fifty-four community-dwelling seniors ≥ 70 years, admitted to acute medicine services for >24 hours at an urban hospital. RESULTS: Of 254 seniors [mean age 79.3 yrs, 53.1% female], 142 (56%) had a medication discrepancy between their discharge instructions and their actual home medication use 48 hrs after discharge. Subjects with inadequate and marginal health literacy were significantly more likely to have unintentional non-adherence--meaning the subject did not understand how to take the medication [inadequate health literacy 47.7% vs. marginal 31.8% vs. adequate 20.5% p = 0.002]. Conversely, those with adequate health literacy were significantly more likely to have intentional non-adherence--meaning the subject understood the instructions but chose not to follow them as a reason for the medications discrepancy compared with marginal and inadequate health literacy [adequate 73.3% vs. marginal 11.1% vs. inadequate 15.6%, p < 0.001]. Another common cause of discrepancies was inaccurate discharge instructions (39.3%). CONCLUSION: Seniors with adequate health literacy are more inclined to purposefully not adhere to their discharge instructions. Seniors with inadequate health literacy are more likely to err due to misunderstanding their discharge instructions. Together, these results may explain why previous studies have shown a lack of association between health literacy and overall medication discrepancies.

Improvements in cognition following hospital discharge of community dwelling seniors.

BACKGROUND: Seniors frequently struggle during the transition home following an acute hospitalization resulting in frequent rehospitalizations. Studies consistently show a lack of comprehension of discharge instructions. OBJECTIVES: To determine the frequency of low cognition at hospital discharge among community dwelling seniors and the changes in cognition that occur one month following hospitalization. DESIGN: Face-to-face surveys were performed at hospital discharge and one month later in the home of the subject. The Mini-Mental Status Examination (MMSE), Backward Digit Span, and 15 Word Immediate and Delayed Recall Tests were used to evaluate cognition. Low cognition was determined to be a score of less than 25 on the MMSE for subjects with high school education and less than 18 for subjects with less than high school education. PARTICIPANTS: Two hundred community-dwelling seniors ≥ 70 years, admitted to acute medicine services >24 hours, consenting to their own procedures, not having previously documented cognitive loss, and not admitted for cognitive changes. RESULTS: Upon hospital discharge, 31.5% of subjects had previously unrecognized low cognition. One month later, 58% of these patients no longer had low cognition (p < 0.001). Of those subjects with low cognition, the MMSE improved by an average of 4 points one month post-discharge. Within the MMSE, subjects experienced significant improvements in the areas of orientation, registration, repetition, comprehension, naming, reading, writing, and calculation. CONCLUSION: Low cognition at discharge is common among elderly patients without dementia, and cognition often improves one month post-hospitalization. Seniors may not comprehend discharge instructions, and patient self-management may be better taught as an outpatient following discharge rather than at the time of hospital discharge. Discharge interventions should incorporate screening of seniors for low cognition prior to hospital discharge to provide optimal transitional care.